Marina Pointe Healthcare: Pain Ignored for Weeks - CA
The resident, identified in inspection records only as Resident 1, is a patient at Marina Pointe Healthcare & Subacute on Sepulveda Boulevard. He has a contracted right arm, meaning the joint has tightened and lost range of motion, a condition common in patients with limited mobility. His family posted the warning after noticing staff were not being careful enough when dressing him or repositioning him. The note asked them to be mindful when touching, moving, or repositioning the arm.
It did not work.
A certified nursing assistant, identified as CNA 4, told inspectors she had watched Resident 1 moan every time the arm was touched. She knew the pain was real. She said she reported it to multiple nurses over time, though she could not remember their names. She had also developed a workaround: putting his shirt on the right arm first, to minimize how much the limb was moved. Even that made him cry out.
But CNA 4 also said she thought the pain might just be normal, because the arm was contracted. She told inspectors she eventually reconsidered that assumption. "If Resident 1 complained of pain with movement," she said, "it could indicate a possible fracture the staff were unaware of and that needed to be addressed or assessed."
A possible fracture. Undetected. In a man who had been moaning for weeks.
The licensed vocational nurse who saw the family's posted note, identified as LVN 2, told inspectors she read it and did nothing. She did not extend the arm or press on it to check for pain. She did not call the family to ask why they had put it there. She did not call the doctor. She did not file a change-of-condition report, the standard internal document used to flag when a resident's health has shifted and a clinical response is needed.
"I assumed the family just posted it," she told inspectors.
LVN 2 then walked inspectors through exactly what should have happened. Staff should have assessed the arm, asked Resident 1 to rate his pain, offered medication, notified the physician, and completed a change-of-condition report. Leaving a resident in unmanaged pain, she said, could cause discomfort and anxiety. She described this sequence clearly and without apparent uncertainty. She simply had not done any of it.
The Director of Nursing confirmed to inspectors that charge nurses were responsible for filing change-of-condition reports when CNAs flagged pain, and that registered nurses were supposed to assess the arm and notify the doctor. The DON also listed the medical risks of unmanaged pain: elevated heart rate, increased respirations, anxiety.
Marina Pointe's own written pain policy, dated October 2022, calls for assessing acute pain or significant worsening of chronic pain every 30 to 60 minutes after onset, then reassessing until relief is obtained. The policy describes a full sequence: identify the pain, find its source, develop a management plan, monitor whether it is working, and adjust if it is not.
None of that happened for Resident 1.
The inspection was conducted on March 27, 2026, following a complaint. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. Marina Pointe is disputing the citation.
What the record does not resolve is how long Resident 1's arm went unexamined, whether he ever received pain medication for it, or whether anyone ever determined if the bone was intact. The family had put a note on the wall because they were worried. The nurses read it and went on with their shift.
Resident 1 kept moaning every time someone touched him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marina Pointe Healthcare & Subacute from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MARINA POINTE HEALTHCARE & SUBACUTE in CULVER CITY, CA was cited for violations during a health inspection on March 27, 2026.
The resident, identified in inspection records only as Resident 1, is a patient at Marina Pointe Healthcare & Subacute on Sepulveda Boulevard.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.